Bruising Bruises are caused by traumatic injury to tissue resulting in damaged underlying blood vessels and with consequent extravasation into the surrounding tissue. Such lesions are non-blanching and fall into the category of ecchymosis (1-3cm in diameter), purpura (3mm-1cm) or petechiae that are much finer. Often the location of extended bruising may indicate an underlying bleeding disorder, such as large ecchymosis on the trunk without known trauma, whereas minor bruising on the extremities is more likely to be benign. Extensive truncal ecchymosis may suggest an acquired coagulation disorder such as liver disease, intravascular coagulation (DIC) or acquired haemophilia. Some generalisations can be made: bruising tends to occur more often in females and those with lighter complexions; and in older people bruising can occur because of laxity of the underlying vascular supporting structures, permitting rupture of small blood vessels.
Causes of Ecchymosis (1-3cm)
Dr Ram Tampi Clinical Haematologist
Causes of Purpura (3mm-1cm) Purpuric lesions arise from a number of conditions (see below) and may display colour changes from red to purple. The hallmark of purpura is partial blanching that suggests not only inflammation but some haemorrhage. It may result from vessel occlusion causing ischaemic damage to the skin. Inflammation around the blood vessel may lead to palpable purpura whereas simple haemorrhage is rarely associated with such a feature unless there is haematoma present. Overall, these lesions occur predominantly in inflammatory vasculitis and sepsis. Small vessels: t 7BTDVMJUJT F H )FOPDI 4DIPOMFJO purpura or meningococcal septicaemia) t *NNVOF DPNQMFY EJTFBTF t 4#& t 8BMEFOTUSPN T .BDSPHMPCVMJOBFNJB Small and medium sized vessels: t .JYFE DSZPHMPCVMJOBFNJB t 3IFVNBUJD WBTDVMJUJT 4-& dermatomyositis, RA) Large vessels:
Q Fig 1. Large bruise on the thigh due to over-anticoagulation.
t "OUJDPBHVMBOU VTF 'JH BOE PS vit K deficiency t 5SBVNB t -JWFS GBJMVSF t 7PO 8JMMFCSBOE T EJTFBTF t %*$ BDRVJSFE )BFNPQIJMJB t "HF SFMBUFE t 4UFSPJE UIFSBQZ t 7JUBNJO $ EFGJDJFODZ
medicalforum
t -FVLPDZUPDMBTUJD WBTDVMJUJT MPDBMJTFE randomly): o Antineutrophilic antibodies BTTPDJBUFE "/$" o Wegener’s granulomatosis, Churg-Strauss, polyangitis. t /PO MFVLPDZUPDMBTUJD o haemorrhage o inflammation o vessel occlusion About a third of cases of cutaneous vasculitis are idiopathic. Others causes may be drug induced (beta blocker drugs, /4"*% NPOPDMPOBM BOUJCPEZ UIFSBQZ with serum sickness, as well as bacterial and viral (HIV, Hepatitis C) infections. Collagen vascular disease (SLE, Sjogren’s, RA), IBD (Crohn’s, ulcerative colitis) and lymphoproliferative neoplasm form the bulk of the rest. Large vessel disease may express itself in Wegener’s granulomatosis,
1"/ PS $IVSH 4USBVTT WBTDVMJUJT Leukoclastic vasculitis with fibrinoid necrosis and neutrophilic degeneration may arise in multiple settings and may be seen with either small or large vessel disease.
Q Close up view of purpura.
Causes of Petechiae (<3mm) Petechiae are pinpoint capillary haemorrhages that are characteristically non-blanching and mainly caused by UISPNCPDZUPQFOJB QMBUFMFUT OM PS abnormalities of platelet function. t 1SJNBSZ PS TFDPOEBSZ thrombocytopenia t $POHFOJUBM BOE BDRVJSFE QMBUFMFU function defects t /PO QMBUFMFU FUJPMPHJFT t $ISPOJD QJHNFOUFE QVSQVSB t )ZQFSHBNNBHMPCVMJOBFNJB t *OUSBWBTDVMBS QSFTTVSF JODSFBTF (e.g. coughing) t 5SBVNB Treatment for simple bruising would follow along the lines of RICE (rest, ice, compression, elevation), analgesics and, in some instances, the use of tranexamic acid may lessen the impact of the bruising. The management of the above lesions depends on the underlying cause and, if remediable, may lead to the resolution of the bruising, ecchymosis, purpura or petechiae. The diagnosis of the type of bruise may be narrowed down by the history and further aided by investigations, which will include a full blood count, coagulation profile, biochemical, immunological and imaging studies. In difficult cases a skin biopsy may be helpful.
7